PROPHYLACTIC ANTIBIOTICS ON LABOR & DELIVERY · 2020-05-27 · • Chibueze et al. Prophylactic...
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©UNIVERSITY OF UTAH HEALTH, 2017 PROPHYLACTIC ANTIBIOTICS ON LABOR & DELIVERY Irina Cassimatis MD, MSc
Transcript of PROPHYLACTIC ANTIBIOTICS ON LABOR & DELIVERY · 2020-05-27 · • Chibueze et al. Prophylactic...
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PROPHYLACTIC ANTIBIOTICS ON
LABOR & DELIVERYIrina Cassimatis MD, MSc
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No disclosures
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ANNUAL U.S BIRTHS
National Center for Health Statistics 2018
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UNIVERSITY OF UTAH DELIVERIES (2017)Cesarean delivery
27%
�Vaginal Delivery
73%
3361 deliveries
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ANTIBIOTIC PROPHYLAXIS
• Goal is to have therapeutic tissue levels at time of microbial contamination
• Agent of choice should be long acting, narrowly focused on the likely bacteria, inexpensive, and have a low incidence of adverse effects
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GENITOURINARY TRACT MICROBIOLOGY
Gibbs, Am J Obstet Gynecol 1987
Gram positiveaerobic
Gram negativeaerobic
Anaerobic Mycoplasma Other
GBS E. coli Peptostreptococcus Mycoplasma Chlamydia
S. auerus Klebsiella Peptococcus Ureaplasma
Enterococcus Proteus Bacteroides
Pseudomonas Gardnerella
Enterobacter
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ANTIBIOTIC MISUSE
• Allergic reactions• GI disturbance• Unknown fetal
effects• Potential healthcare
costs• Antibiotic resistance
Ledger. BJOG 2013Stiemsma. Pediatrics 2018
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CLOSTRIDIUM DIFFICILE
Lessa et al. N Engl J Med 2015
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C. DIFF AMONG PERIPARTUM WOMEN
Kuntz et al. Infect Control Hosp Epidemiol 2010
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OBJECTIVES
• Post-op antibiotics following cesarean in BMI > 30
• Cesarean complicated by Triple-I• Manual placental removal• Obstetric anal sphincter injury
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CESAREAN AS RISK FACTOR FOR INFECTION
• Surgical site infection (SSI) following cesarean section: – reported rates of 3–20 %
Costantine et al. Am J Obstet Gynecol 2008
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OBESITY IN PREGNANCY
CDC. National Center for Chronic Disease Prevention and Health Promotion, 2018
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UNIVERSITY OF UTAH – DELIVERY TYPE BY BMI
BMI <2950%
BMI 30-34
28%
BMI 35-3913%
BMI >409%
PERCENTAGE OF DELIVERIES BY BMI
0
200
400
600
800
1000
1200
1400
BMI <29 BMI 30-34 BMI 35-39 BMI >40
VDCS
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CEFAZOLIN DOSING FOR BMI > 30
• Standard dose recommendation: 2g cefazolin within 60 minutes of incision
Bratzler et al. Am J Health Syst Pharm 2013
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Post-cesarean extended oral prophylaxis in BMI > 30
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POST-CESAREAN ORAL KEFLEX AND FLAGYL
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POST-CESAREAN ORAL KEFLEX AND FLAGYL
Valent et al. JAMA 2017
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INTACT VS RUPTURED MEMBRANES
Valent et al. JAMA 2017
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Cesarean section in the setting of Triple-I infection
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TRIPLE-I TREATMENT
Hopkins. Cochrane Database Syst Rev 2002
Antibiotic DoseAmpicillin 2g q6h PLUSGentamicin 5mg/kg daily OR 1.5mg/kg q8h
Ampicillin-sulbactam 3g q6hTicarcillin-clavulanate 3.1g q4hCefoxitin 2g q8hCefotetan 2g q12Pipercillin-tazobactam 3.375g q6h
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CEPHALOSPORINS VS AMINOPENICILLINS
• First generation Cephalosporins vsAminopenicillins– 7 studies; 1487 women
– No significant difference in maternal endometritis
• (RR = 1.09, CI 0.69 – 1.71)
Gyte. Cochrane Database of Syst Review 2014
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UREAPLASMA COVERAGE IN TRIPLE-I
Sweeney at al. Clin Microbiol Rev 2017
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MACROLIDE THERAPY AT TIME OF CESAREAN
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Antibiotic prophylaxis in the setting of manual placental removal
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UNIVERSITY OF UTAH – MANUAL PLACENTAL REMOVAL
Manual removal of placenta
Cefazolin given
2015 472 418 (89%)
2016 448 412 (92%)
2017 334 238 (71%)
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ANTIBIOTICS AT TIME OF PLACENTAL REMOVAL
• NO RCTs to evaluate effectiveness of antibiotic prophylaxis to prevent endometritis after manual removal of placenta
Chongsomchai. Cochrane Database of SystReviews 2014
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MANUAL REMOVAL – SYSTEMATIC REVIEW
Chibueze et al. BMC Pregnancy Childbirth 2015
Observational studies: systematic review– Three eligible cohort studies (n=567)
– Primary outcome: puerpural fever or endometritis
– Results: no difference • (OR = 0.84, 95 % CI 0.38 to 1.85)
– Limitations: • small number of low quality non-randomized studies
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Obstetric anal sphincter injuries (OASIS)
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OASIS
• Anal sphincter injuries: up to 24% of obstetric vaginal lacerations
• Wound breakdown: 0.1- 5% of obstetric vaginal lacerations
Williams. Obstet Gynecol 2006
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OBSTETRIC LACERATION PROPHYLAXIS - RCT
• Intervention: single dose of 2nd or 3rd
generation cephalosporin at time of repair
• Primary outcome: evidence of a perinealwound complication at the 2-week postpartum visit
Duggal et al. Obstet Gynecol 2008
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PERINEAL WOUND COMPLICATIONS
Duggal et al. Obstet Gynecol 2008
8.2%
4.1%
8.2%
20.7%
7.2%
24.1%
0%
5%
10%
15%
20%
25%
30%
Wound disruption Purulent discharge Wound complication
Perineal wound complication rates (%)
Antibiotic Placebo
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In Summary…
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CESAREAN PROPHYLAXIS IN OBESITY
• 48 hours of Keflex and Flagyl requires additional studies
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CESAREAN IN THE SETTING OF TRIPLE-I
• Add Clindamycin at time of cesarean
• Additional cephalosporin not necessary
• Azithromycin: probably beneficial, excellent research question
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MANUAL PLACENTAL REMOVAL
• Antibiotics probably not necessary
• Another great research question!
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OASIS
• Complications devastating
• Potential to reduce morbidity outweighs possible side effect of antibiotic administration
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QUESTIONS?
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REFERENCES • ACOG Practice Bulletin No. 120. Use of prophylactic antibiotics in labor and delivery. Obstet
Gynecol 2011; 117(6): 1472–1483.• Ahmadzia HK, Patel EM, Joshi D, Liao C, Witter F, Heine RP et al. Obstetric surgical site infections: 2 grams
compared with 3 grams of cefazolin in morbidly obese women. Obstet Gynecol 2015; 126(4): 708–715.• American College of Obstetricians and Gynecologists Committee Opinion No. 465. Antimicrobial prophylaxis
for cesarean delivery: timing of administration. Obstet Gynecol 2010; 116(3): 791–792.• Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health
Promotion, Division of Nutrition, Physical Activity, and Obesity. Data, Trend and Maps [online]. [accessed Apr 10, 2018].
• Chibueze et al. Prophylactic antibiotics for manual removal of retained placenta during vaginal birth: a systematic review of observational studies and meta-analysis. BMC Pregnancy and Childbirth. 2015
• Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. Cochrane Database of Systematic Reviews 2014, Issue 10. Art.
• Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol. 2008;199(3):301.e1-301.e6.
• D.W. Bratzler, E.P. Dellinger, K.M. Olsen, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery Am J Health Syst Pharm, 70 (2013), pp. 195-283
• Duggal N, Mercado C, Daniels K, et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 2008; 111:1268.
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United States. N Engl J Med. 2015;372(9):825–34.• Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, et al. Wound complications after obstetric anal sphincter
injuries. Obstet Gynecol. 2015;125:1088–1093.• Maggio L, Nicolau DP, DaCosta M, Rouse DJ, Hughes BL. Cefazolin prophylaxis in obese women undergoing
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